Abstract
The final appearance of mass testing as a tool for viral suppression, 10 months into the COVID-19 pandemic, revealed tensions between academic epidemiologists who questioned whether this novel approach would work in theory even if it worked in practice, and frontline public health teams who at last seemed to be being recognised for their hands on practical expertise.
Such experience of grounded and pragmatic intervention at the local level dates back 170 years and long predates the advent of blue sky academic departments with their contentious modelling efforts and arguable theories of screening based on non-communicable disease. With the repeat heralding of the arrival of mass vaccination (by Christmas, by Easter, by Summer?), there seemed at last to be a glimmer of light at the end of the tunnel, but the recriminations have barely started.
I have chronicled the failings of omission and commission of the government and its advisers in my book Blinded by Corona and hopefully its findings will in due course inform the deliberations of the inevitable public enquiry. 1 Meanwhile, fundamentalist commentators have begun to question whether the public health approach to the pandemic was mistaken in its entirety, suggesting in the case of one free marketeer commentator that ‘groupthink is the disease that has forced us into this crisis’ before laying in to those politicians and scientists with their ‘illusion of control’ who believe they can dominate the virus by pulling levers such as lockdowns. 2
For such critics, channelling Adam Smith’s invisible hand of the social benefits of individual self-interested actions, public health interventions acquire the characteristics of totalitarians, such as the Communist Party in China. 3 In eschewing science in favour of the cybernetic cycles of the natural world, they echo a strange assembly of bedfellows including not only Adam Smith but Charles Darwin and the natural selection of the fittest; James Lovelock, whose Gaia hypothesis postulated that the planet was part of a self-correcting system; Thomas Gradgrind, the school board superintendent in Charles Dickens novel Hard Times, who knew the price of everything and the value of nothing; and the editor of The Times of London who trumpeted that ‘We would rather take our chances with the cholera than be bullied into health by the likes of Mr Chadwick’.4–6
When Archie Cochrane published his influential tract on effectiveness and efficiency in the NHS in 1972, his intention was to throw light on the optimal use of resources in the protection and improvement of health. 7 Unfortunately, he set a series of hares running with evidence-based medicine that led to a preoccupation with the randomised controlled trial as the gold standard for the evaluation of health services. This distracted attention from public health and led to a narrowing of the frame of reference from the social administration of Brian Abel Smith and the London School of Economics with its interest in total cost accounting to a health service economics that gave us the quality-adjusted life year. 8 This has assumed a new importance for those who seem content to sacrifice older victims of COVID-19 to their fate, arguing that as most victims of COVID-19 are near the end of their natural life, the costs of achieving each quality-adjusted life year are far too great to justify robust public health measures such as a lockdown.
Ironically, in broadening the discussion from mortality to economics, such objections to public health make explicit many of the other issues that have been ignored or overlooked during the pandemic: mental health; heart disease; unemployment; bankruptcy; national debt; suicide; domestic abuse; evictions and homelessness; and civil liberties. In widening the focus away from the narrower prism that has driven much health economics in the recent past, we are challenged to put all the cards on the table in pursuit of policies that are both coherent and humane.
The missing ingredient, as in so much of the handling of this once in a century crisis, has been the full engagement of the public through open and transparent communication of this full picture and an approach to active citizenship that goes beyond the lies and manipulation of data that have characterised its handling for the past year.